Patient Safety, Human Factors and PSIRF Insights for Healthcare Organisations

Martha’s Rule is changing care when patients deteriorate and concerns go unheard. Its deeper value lies in what every activation reveals about the safety of the system.

Using George Eliot’s candle metaphor and Daniel Kahneman’s WYSIATI principle, Katie Franklin explores how partial perspectives shape judgement, why blame culture restricts learning, and how psychological safety, diversity and just culture help organisations see more clearly

Poppy Russell’s preventable death and her family’s response ask a wider question of the NHS: do we treat listening as a courtesy, or as a safety intervention? This article connects compassion, PSIRF, family liaison, candour, human factors and good governance.

A listening organisation does more than invite people to speak. It hears weak signals, responds with curiosity and acts before warning becomes harm.

What does George Orwell's Nineteen Eighty-Four have to do with healthcare investigations? More than you might think. Investigators hold the pen, shaping how events are understood and what organisations learn. Exploring PSIRF, Human Factors and Safety-II thinking, this article examines the power of investigative narratives, the risks of confirmation bias and premature closure, and why meaningful patient safety learning depends on curiosity, evidence and systems thinking.